Expert Critique

The National Cancer Institute defines cancer health disparities as "adverse differences in cancer incidence (new cases), cancer prevalence (all existing cases), cancer death (mortality), cancer survivorship, and burden of cancer or related health conditions that exist among specific population groups in the United States." Although work to address cancer health disparities has been underway for the last 20 years, recent data demonstrate that inequities, although decreasing, are still present.

NCI data show that over the last decade, cancer deaths have declined for both white and African American patients living in the United States, but African American patients continue to suffer the greatest burden for each of the most common types of cancer, including lung cancer.

Much research has focused on addressing the racial inequities in thoracic oncology in particular. These efforts were in part spurred by the 2006 paper by Christopher Lathan et al in JCO, “The Effect of Race on Invasive Staging and Surgery in Non-Small Cell Lung Cancer,” which demonstrated that African-American patients were less likely than white patients to receive stage-appropriate cancer care, including complete invasive staging and surgical resection.

This study and others increased awareness of racial disparities and did lead to change. In fact, the cancer death rate for men in the U.S. declined faster among African Americans than among men of any other racial or ethnic group -- due mostly to decreases in lung cancer. However the cancer death rates for African American men still remain about 30% higher than for their Caucasian counterparts, illustrating that there is more work to be done.

Collaborative efforts are necessary to address this glaring and persistent problem. As detailed in this news article, investigators like Stephen Coughlin’s group are working to not only identify the causes/contributors to racial inequities (access to care, health literacy, socioeconomic status, and patient and provider factors), but also striving to address these issues in clinical practice and to further close the gap. In addition, the NCI's commitment to underserved populations continues to grow and mature over the years, and it is now 15 years since the institute established the Center to Reduce Cancer Health Disparities in 2001 to serve as the cornerstone of NCI's efforts to reduce the unequal burden of cancer in our nation.

Continued awareness of this issue coupled with collaborative efforts to address the problems will hopefully culminate in the eradication of cancer health disparities in the not-so-distant future.

Full Critique

Christopher Lathan, MD, MPH, Medical Director of Dana-Farber Cancer Institute at St. Elizabeth's Medical Center in Brighton, Mass., and colleagues set out 10 years ago to determine why black patients obtained less surgery for lung cancer than white patients did.

After examining information from patients with nonmetastatic non-small cell lung cancer (NSCLC) in the Surveillance, Epidemiology, and End Results (SEER) database from 1991 to 2001, the researchers found that black patients were less likely to both undergo staging (OR=0.75, 95% CI 0.67-0.83) and to have surgical resection than white patients were (OR=0.55, 95% CI 0.47-0.64).

The team also noted that staged black patients were less likely to receive a recommendation for surgery when it was not clearly contraindicated (67% versus 71.4%), although they also were more likely to decline to have surgery (3.4% versus 2.0%).

However, when blacks and whites did have surgery, the data showed that survival was equivalent after resection (HR=1.02).

That study is believed to be the first to examine the role of invasive staging in obtaining surgery for patients with early-stage lung cancer, the researchers said. Among the noteworthy findings were that:

Black patients do not have surgery for early-stage lung cancer at the same rate as white patients with similar-stage disease and comorbidity do

Black patients are less likely to be staged, and even when staged, they are still less likely than white patients to have surgery

When black patients do have surgery, their survival experience is similar to that of whites

Black patients have surgery recommended significantly less often than white patients do, and are also refusing surgery more often

Now, a decade later, has the treatment of lung cancer care improved for black patients? In at least the sense that there is greater awareness of treatment disparities in this population, the answer is yes, according to a recent report from the American Lung Association. But much more work is still needed: "This group suffers from lung cancer more than any other population group in the United States. They are more likely to get it, and more likely to die from it. African-American men in particular are at increased risk; they are 37 percent more likely to develop lung cancer than white men, even though their overall exposure to cigarette smoke -- the primary risk factor for lung cancer -- is lower," the document noted.

The awareness of the disparities is being translated into clinical practice, although closing the gap is a slow process. In good news, the cancer death rate for men in the U.S. declined faster among African Americans (from 2000 to 2009) than among men of any other racial or ethnic group, due mostly to decreases in lung cancer, according to a 2013 report from the American Cancer Society (ACS). Specifically, the disparity in lung cancer death rates between African-American and white men was eliminated in adults younger than age 40, likely because fewer young African Americans smoked tobacco, according to the report.

Yet "while cancer death rates among African-American men have been declining rapidly, those rates remain 33% higher than the rates among white men -- evidence that more can and should be done to accelerate this progress by making sure all Americans have equal access to cancer prevention, early detection, and state-of-the-art treatments," stressed Otis Brawley, MD, ACS chief medical officer, in a written statement.

In 2014, Steven Coughlin, PhD, MPH, now at Emory University in Atlanta, and colleagues at the University of Tennessee College of Medicine in Memphis, looked at opportunities to address lung cancer disparities in the African-American population. "Although decades-long efforts have been made to study the determinants of health disparities and to identify effective ways to address these inequities, health disparities and inequalities have been remarkably persistent," the team noted in a review article.

They echoed some of the data revealed by Lathan's group, that black patients are less likely to receive surgical resection than whites are, and that African Americans appear to have the lowest survival rates among all groups for early-stage NSCLC.

The reasons for the disparities remain complex and encompass patient, environmental, and health system factors, Coughlin's group pointed out. These include misperceptions of lung cancer risk, particularly by smokers in the African-American community; a lack of trust in physicians because of poorer patient-physician communications; and the fact that chronic diseases are more common among socioeconomically disadvantaged persons.

In addition, "higher educational attainment and higher economic status are associated with greater understanding of the state of the science on smoking and lung cancer," the review stated -- statistics that were borne out by a study presented at the most recent American Society of Clinical Oncology annual meeting.

Kerri McKie, an MD candidate at the University of Massachusetts Medical School in Worcester, and colleagues conducted a retrospective review of the SEER database from 2004 through 2012.

The study focused on the inter-relationship of economic and racial/ethnic differences in the presentation and survival of lung cancer patients. The analysis included a total population of 156,405 patients, the majority (74.4%) of whom were non-Hispanic white, followed by blacks (12.3%) and Hispanics (5.7%), with the remainder comprising Asian, Native peoples, and other ethnicities.

The median annual income of the non-Hispanic white group and the Hispanic group was calculated at $55,910; the African-American population showed a median annual income of $51,460. The mortality status due to lung cancer was 56.8% for non-Hispanic whites, 56.9% for the Hispanics, and 58.6% for African Americans.

The authors noted that as compared with the other populations, blacks were more likely to present with younger age, male sex, lower mean income, no insurance, and advanced-stage disease, and were more likely to have no definitive surgery, have lower overall survival, and have more lung cancer deaths.

In addition, the non-Hispanic white and Asian populations were more likely to present with stage I disease and to have surgery recommended and performed as compared with the situation for black, Hispanic, and other ethnic populations.

Overall, independent of race and economic status, the percentage of stage I disease progressively decreased (54.15% to 43.5%) over the 8-year period reviewed in the study, while stage IV disease progressively increased (13.1% to 21.1%).

Equal Patients, Equal Outcomes

What more can the cancer community do to continue addressing this disparity? Ensuring that African-American patients receive optimal care is key. Back in 2006, Brawley pointed out that "the population-based Lathan study not only demonstrates that there is not equal treatment, it demonstrates that equal treatment yields equal outcome among equal patients."

Brawley noted that although there has been tremendous emphasis on the study of drugs possibly having less effect in blacks, there seems to be little interest in the fact that many studies show that blacks are at greater risk to receive less than optimal treatment for a number of cancers.

Coughlin's group laid out more specific avenues for boosting quality care in this population, including:

Emphasizing smoking cessation by informing patients of the short-term benefits of quitting smoking, as related to their cancer treatment, and about the long-term benefits related to increased survival

Improving patient-physician communications through "cultural competency," defined as knowledge about culture and cultural differences among patients of different racial, ethnic, and socioeconomic backgrounds

Addressing low health literacy by producing cancer prevention and control messages that take into consideration populations with "marginal literacy skills"

Using patient navigators to ensure that patients receive complete and timely disease staging and treatment, as well as to help patients maximize quality of life.

"Moving a patient through a lung cancer care/cancer continuum is a complex and individualized process," Coughlin et al. concluded. "Cancer care is often fragmented, inadequately coordinated, and not always organized around the needs of the patient. As lung cancer and other diseases become more preventable due to advances in medical knowledge, individuals with greater access to resources tend to benefit more, which can lead to the worsening of health disparities."

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.